9435 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
n UILDING APPLICATION & PERMIT
\. ADDRESS
a BUILDING -ELECTRICAL-PLUMBING-MECHANICAL9435
NANEn'S PLAN CHECK VALIDATION
X\ NAME DTY. ELECTRIC PERMIT FEE
• CONTRACTORS M 'a 1 UTEETS-SWITCHES-RECEP 10.00/1.00
NAMELIC.NO. LIGHTING FIXTURES 10.00/1.00
DDRESS oRs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS 10.00 DATE OF APPLICATION
oncnrTEGT PANELS (OVER 200 AMP) 20.00 PLAN CNECK FEE P.C.NO.
ENGINEER
uc.Ro. SIGNS TRANS. 3.00
nooa ass ENG' SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. n
ADDRESS Ess f1(/\
SERVICE CHANGE 20.00 p
�0o LICENSED CONIRACTORS DECLARATION TEMP,POLE 30.00
F i w I hereby o1inn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
so ¢ as (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r D i Professions Code,and my license is in full force and effect. ❑ ❑
o
z w o License Class Lie.Number _
Date Contractor
a m s BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
0 > U INFORMATION
X S, LL H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a_ o ¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
�'y •� Code:Any city orcounty which requires a permit to construct.alter.
rtau Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- LL requires lite applicant for such permit to file a signed statement that TOTAL PERMIT TO
X m he is licensed pursuant to lire provisions of the Contractor's License
z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe PL�
i o Business and'Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
or F m lire basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a by any applicant for a proof subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($5001):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sol,compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or uttered for sale (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'I'Ile Contractor's Licence Low docs not apply to an owner of
property who builds on reprOVe,thcreOn,red who due,fact,work FIXTURES-PER TRAP 5.00 SO:FT.FLOOR AREA TOTAL ACREAGE
• himself of through his own employees,provided that such improve- _
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INCA OUTLETS 8.00 (�
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 ' RES IND CON PB CO.,
❑ 1,as owner of tire . .
property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 6.00
recon
Owner Dole q'FS`J WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKI'RS'COSATI IPI'.NSN DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy th,reof(Sce.3800,Lab.C).
Policy Ncu Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Cerlified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ I Y ❑ NE]Cc m CER'I'IFICA'1'1:OP FXFMPILON FROM WORKERS' PERMIT ISSUANCE 10.00 O FLOOOZONE A.L.0 c. '
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. 0-'C"/ CL 0 (This section need not be completed if the permit is for one TOTAL /� _ Y❑ N[JY E) N❑
hundred dollars($100)or less.)
r U O 1 certify ilial in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL h mit is issued,1 shall not employ any person in any manner so as m
Q w become subject to lite Workers'Compensation Laws of California
C_ Date. Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE '10 APPLICANT: If,after making this Certificate of Ex-
f- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.CIv.C). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application andslate that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING /
ordinances and slut, laws relating to building construction, mal BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 LO �.
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of Lhe
granting of this perm it. MECH.CONT. LIG NO. MECH.
dal �• TOTAL TOTAL
Si m ppIfn/C u L r Dare
INSPECTOR COPY